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General NPI Number Information
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NPI Number | 1033252622
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Entity Type | Individual
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Provider Name | TRAVIS AARON DEAN LCSW
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Gender | Male
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Dates
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Enumeration Date | 02/14/2007
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Last Update Date | 02/03/2020
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Provider Practice Location Address
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Address Line | 1337 E 17TH ST
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City | IDAHO FALLS
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State | ID
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Zip | 83404-6235
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Country | US
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Telephone | 208-525-2090
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Fax | 208-523-8978
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Provider Business Mailing Address
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Address Line | 3820 E 180 N
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City | RIGBY
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State | ID
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Zip | 83442
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Country | US
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Telephone | 208-745-0639
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | LCSW-27235
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License Number State | ID
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